TKD NursingGuidelines Percutaneous

8/16/2019 TKD NursingGuidelines Percutaneous

http://slidepdf.com/reader/full/tkd-nursingguidelines-percutaneous 1/30

TURKISH

SOCIETY OF

CARDIOLOGY

NURSING CAREGUIDELINESIN PERCUTANEOUSCORONARY AND

VALVULARINTERVENTIONS



3

TURKISH SOCIETY OF CARDIOLOGY

NURSING CARE GUIDELINES

IN PERCUTANEOUS CORONARY

AND VALVULAR INTERVENTIONS

FEBRUARY 2007

© Turkish Society of Cardiology ISBN 9944-5914-2-4



NURSING CARE GUIDELINES IN PERCUTANEOUS CORONARY AND VALVULAR INTERVENTIONS

CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

1. Percutaneous Coronary Interventions . . . . . . . . . . . . . . . . .10

1.1. Percutaneous transluminal coronary angioplasty (PTCA) . . . . . . . . . . . .10

1.2. Percutaneous coronary atherectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .10

1.3. Percutaneous coronary laser angioplasty . . . . . . . . . . . . . . . . . . . . . . .10

1.4. Percutaneous coronary stent placement . . . . . . . . . . . . . . . . . . . . . . . . .10

1.5. Bracytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

2. Percutaneous Valvular Interventions (PVI) . . . . . . . . . . . . .11

3. Risk Factors in Percutaneous Coronary and Valvular

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114. Complications in Percutaneous Coronary and Valvular

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

4.1. Major complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

4.2. Minor complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

5. Nursing Care in Percutaneous Coronary and Valvular

Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

5.1. Nursing diagnoses-interventions in percutaneous coronary and

valvular interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145.2. Patient/Family Education Before Discharge . . . . . . . . . . . . . . . . . . . . . .26

6. Pulse Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

7. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30



NURSING CARE GUIDELINES FOR PERCUTANEOUS CORONARY AND VALVULAR INTERVENTIONS

My Dear Colleagues,

Despite the passage of a very short time since the foundation of TSC the

Cardiovascular Nursing and Technicianship Group has spared no effort to publish‘’Nursing Care Guidelines in Cardiac Failure, Acute Coronary Syndromes and

Hypertension’’ in 2003 and ‘’Nursing Care Guidelines in Percutaneous Coronary

and Vascular Interventions’’ in 2004. These two publications have been well-

received and distributed to all of our members. As the stocks have run out it has

been necessary to republish the present new editions for the benefit of our new

members and especially the nurses and the technicians. In this context I am happy

to anounce that our study group is working on a new guideline publication.

I do believe that the representation of these guidelines prepared with great

diligence by nurses and specialist cardiologists will be of great use to our

members. I would like hereby to reitirate my thanks to all of our contributing

members.

I would like to take this opportunity to emphasize that the educational programs

started by the Cardiovascular Nursing and Technicianship Group, theirparticipation in other activities of TSC as well as making their presence felt in the

European Cardiology Association has been recognised with great appreciation.

Our association will continue to give them all the possible support.

Looking forward to many more successful cooperations and with best regards,

Prof. Dr. Çetin ErolTSC President



7


GUIDELINES PREPARATION COMMITTEE

Prof. Nuray Enç, RN, PhD

Prof. Sabahattin Umman, MD

Prof. Mehmet A¤›rbafll›, MD

Meral Gün Alt›ok, RN, PhD

Fisun fienuzun, RN, PhDHilal Uysal, RN, MScN

Emine ‹ncekara, RN, MScN

Serap Ulusoy, RN

Ayfle Eken Baran, RN




INTRODUCTION

Coronary heart diseases constitute the most important health problem affectingpeople of productive age.(1-3)

Mortality due to cardiovascular diseases is one of the leading causes of death,in spite of all the preventive and therapeutic improvements and new methodsdeveloped in this field.(4) Since cardiovascular diseases continue to be the mostimportant cause of mortality and morbidity, there is intense research on this subjectand different treatment methods are being developed. Therefore increasing numberof patients are undergoing diagnostic and therapeutic interventions in the invasivecardiology laboratory.(1-3) Therapeutic percutaneous coronary artery interventions(non-surgical, done via skin route) have been performed since 1980s in the worldand since 1986-87 in our country with an increasing rate since 1995. (5)

1. PERCUTANEOUS CORONARY INTERVENTIONS

1.1. Percutaneous Transluminal Coronary Angioplasty (PTCA): PTCA isan invasive procedure used to eliminate stenosis in the coronary arteries by insertiona catheter through the skin and moving forward through the veins. At the last stage,a balloon catheter is inserted in the coronary arterial lesion and the balloon isinflated at the level of occlusion to open the lumen.(3,6-13)

1.2. Percutaneous Coronary Atherectomy: Atherectomy tools providealleviation in symptomatic patients with coronary artery disease (CAD) by twoprimary mechanisms:(1) Decreasing the stenosis and increasing the distensibility(compliance) of the artery by partial removal of the atherosclerotic plaque,(2)

widening the artery at the level of plaque formation.(1,4,6,10,13-16)

Partial removal of the plaque material by atherectomy and decreasing theresistance of the plaque by dilation renders a smoother and a more regular lumenthan achieved by angioplasty.(17)

1.3. Percutaneous Coronary Laser Angioplasty: Laser (light amplificiationby stimulated emission of radiation) is a high-energy artificial light. One of the

various forms of laser beam is “excimer” laser which is used in plaque ablation incoronary arteries.(1,10,13-16,18)

1.4. Placement of Percutaneous Coronary Stent: Stents are tubular metal-webs placed to maintain or increase vascular patency obtained by balloonangioplasty.(9,11,12,19)

Coronary stents are used to achieve one of two important aims. First, to increasearterial patency achieved by balloon angioplasty and second to minimize the riskof restenosis. Recently new stents have been developed for this

purpose.(6,8,13,14,16,18,20,21)

8




1.5. Brachytherapy: Brachytherapy is a new and developing technique. It is performedto decrease the risk of restenosis after stent placement or balloon angioplasty.(22)

2. PERCUTANEOUS VALVULAR INTERVENTIONS (PVI)

PVI is a therapeutic procedure performed by using balloons of appropriate size forthe dilation of stenotic valves.(6,8,13,14,20,23-25)

3. RISK FACTORS IN PERCUTANEOUS CORONARY OR VALVULARINTERVENTIONS(26)

A- Patient characteristics

a- Previous history of MI (shorter the time between MI and the procedure, higheris the risk),

b- Functional capacity of NYHA III or IV,c- High burden of atherosclerotic plaques,d- Having multiple risk factors,e- Very young or very old age, female gender,f- Hemodynamic instability, shock, renal insufficiency, peripheral artery disease,

diabetes mellitus,g- Use of intraaortic balloon pump, previous history of coronary artery intervention,

multi-vessel disease, previous history of CABG.

B- Surgeon characteristics

a- Lack of knowledge, skill, experience and attention,b- Inadequate or inappropriate information given, preparation or follow-up of the

patient.

C- Institutional characteristics

a- Quantitative or qualitative inadequacy of equipment and tools,b- Insufficient surgical support.

Some of the risk factors may be diminished, but total risk can never be reduced

to zero in any institution.4. COMPLICATIONS IN PERCUTANEOUS CORONARY AND

VALVULAR INTERVENTIONS(11,12,16,18-20,25,27,28)

4.1. Major Complications

- Acute reocclusion (PTCA)- MI (PTCA, PVI)- Emergency Coronary Artery By-Pass Graft Operation (CABG)- Rhythm and conduction disorders reducing cardiac output significantly (cardiac

arrest etc.) (PTCA, PVI)- Severe bleeding in the groin (PTCA, PVI)

9



10


- Accidental dissection of the valvular ring (PVI)- Cardiac tamponade due to rupture or tear in the wall of coronary artery or heart

chambers (PTCA, PVI)- Acute heart failure (PVI)

- Death

4.2. Minor Complications

- Side branch occlusion (PTCA)- Ventricular/atrial arrhythmias (PTCA, PVI)- Bradycardia (PTCA, PVI)- Left-to-right shunt (PVI)- Hypotension (PTCA, PVI)- Blood loss (PTCA, PVI)

- Arterial thrombus (PTCA)- Coronary embolism (PTCA)- Emergency recatheterization (PTCA, PVI)- Severe blood loss requiring transfusion (PTCA, PVI)- Ischemia in the cannulated extremity (PTCA, PVI)- Decrease in renal functions due to contrast medium (PTCA)- Systemic embolism (PTCA, PVI)- Hematoma in the groin, retroperitoneal hematoma, pseudoaneurysm, A-V fistula

(PTCA, PVI)

Sinus

branch

(Left) Maincoronary

artery

Rightcoronaryartery

Circumflex

artery

Coronary arteries and branches

L ef t an t er i or d e s

c en d i n g

ar t er y

First obtuse

marginal branch

Second obtusemarginal branch

Firstdiagonal branch

Seconddiagonal branch

Aorta

Conusbranch

Posterolateral

branchRightventricular

branchP o s t er i or d e s c en d i n g

ar t er y



11


5. NURSING CARE IN PERCUTANEOUS CORONARY AND VALVULARINTERVENTIONS

Responsibilities of the nurse involved in the care of the patient undergoing

interventional therapy;1- Prevention and early diagnosis of potential complications,2- Education of the patient and the family,3- Rehabilitation.

Prevention and early diagnosis of potential complications, individualized andstructured care, education of the patient and his/her family, modification of riskfactors and life style changes are the most important factors affecting prognosis ininterventional treatment.(9,11,12,17,19)

It is important for the nurse to follow recent advances and published literatureand join nursing seminars for the improvement of her knowledge aboutindividualized and structured patient care and education of the patient and thefamily.

Nursing care in percutaneous and valvular interventions are similar.(20,24) Careis given in the context of nursing process. Nursing diagnoses are made accordingto medical and nursing history of the patient, physical examination, hemodynamicfollow-up, analysis and interpretation of data including the results of diagnostic tests;care is planned and reassessed.(29-32)



5.1. Nursing Diagnoses-Interventions in Percutaneous Coronary andValvular Interventions

NURSING DIAGNOSIS - 1

ANXIETY / FEAR(33-38)

12


DIAGNOSTIC CRITERIA(Symptoms and Signs)

• ↑ blood pressure (BP), pulserate and number of breaths

• Tension, irritability,nervousness, crying

• Headache, light headedness• Palmar sweating

• Attention deficit• Pupillary dilation• Dyspnea• Palpitation• Dry mouth• Frequent urination• Tingling in hands and feet

CAUSE

• Having one-sided,exaggerated andnegative informationon interventionaltreatment process,outcomes andpotentialcomplications.

AIM

• Decreasing thepatient's anxiety/fear,

• Developing effectiveways of coping withstress.

INTERVENTIONS

• Anxiety/fear level of the patient is assessed (posture, difficulty infalling asleep, restlessness, tension, fatigue),

• The ways the patient uses for coping with stress are identified.Causes of anxiety/fear are investigated (anxiety due to theprocedure, inadequate information, getting used to the clinics,noise etc.),

• It is explained to the patient that the nurse is well aware of theanxiety/fear the patient experiences,

• Patient's participation in the process of care is provided,• Clear and understandable words are used during the education,

• The intervention laboratory and the staff are introduced to thepatient,

• Therapeutic communication techniques are used (patient isallowed to ask questions),

• Communication with other patients who had experiencedPTCA/PVI is provided when needed,

• Help is provided for the patient while implementing techniques todecrease anxiety (relaxation, deep breathing, positive thinking,and promoting to express him/self),

• Sedative drugs can be given the night before the procedure

according to the physician’s orders.

ASSESSMENT

Expected Outcomes• Expression of

decrease inanxiety/fear by thepatient,

• Use of relaxationmethods effectivelyby the patient,

• Decrease insymptoms of

psychomotoragitation



13



KNOWLEDGE DEFICIT(7,23,34,37,39)


• Being willing to get moreinformation,

• Asking more or lessquestions,

• ↑ anxiety,• Restlessness

CAUSE

• Having inadequateinformation about theprocess planned to beperformed.

AIM

• Decreasing the patient’sanxiety,

• Increasing level ofknowledge.

INTERVENTIONS

• Definition of PTCA/PTI is done by the physician• Pre-interventional education:- The patient is told that oral feeding will be ceased 8 hours before

the procedure and the reasons are explained,- Purpose of laboratory tests, ECG and chest X-ray are explained to

patient,- Catheterization laboratory and the staff are introduced to the

patient,- Informed consent form and its purpose of use are explained to the

patient.- Reason for shaving both groins is explained to the patient.

• Interventional education:- Site of intervention is shown to the patient.- Local anaesthetic agent to be used for the procedure and its effect

is explained to the patient,- Radiocontrast medium to be used for the procedure and its effects

(sensation of warmth during injection) is explained to the patient,- Reasons of taking and holding a deep breath and coughing

according to the instructions given by the physician during theprocedure are explained and exercised,

- Reasons of burning sensation and pain felt during inflation of theballoon are explained.

• Post-interventional education:- Timing of removal of the cannula inserted in the groin during the

procedure,- Importance of mobility restriction and bed rest during the

cannulated period and after the removal of the cannula,- Application of pressure, sand bag and firm bandage to site of

procedure after removal of the cannula is explained;- The monitoring unit where the patient will stay after the procedure

is introduced,- All patient care activities that will be carried out are explained• Post-discharge and homecare education:- The patient is told that he/she may be discharged the morning

after the procedure unless there is any complication,- Dates and importance of visits are explained.

ASSESSMENT

Expected Outcomes• Definition of

PTCA/PVI is madeby the physician,



14



SAFE PREPARATION FOR PTCA / PVI(8,30,31,34,39-42)

AIM

• To prepare the patient safely for PTCA/PVI.

Most common drugs used in PTCA and PVI (Table 1-Page 29)

• Antiaggregants (aspirin, clopidogrel, tirofiban etc.)• Anticoagulants (heparin, low molecular weight heparins, especially enoxaparine)• Intracoronary or IV nitroglycerin

INTERVENTIONS

• It should be checked whether the patient stopped oral intake 5-6 hours before theprocedure. However, if there is a delay long-term starvation and thirst are not allowedto continue. Currently, fluid restriction is not required particularly before diagnosticprocedures.

• PTCA/PVI-related procedures are completed: Whole blood count, coagulation tests,electrolytes, BUN, creatinine, blood group identification and crossmatch, chest x-ray.

• The patient signs an informed consent form,• Groins are shaved bilaterally,• Vital signs are checked,• 12-lead ECG is done,• Help is provided for the patient to carry out excretory functions,• Dentures, accessories and nail polish are removed,• Pulses are detected and marked,• Intravenous access is achieved,• A sedative drug is given according to the physician’s order,• Medications are given according to the physician's order,• The patient puts on a cap and a gown and wears an identity card,• The patient is taken to the angiography laboratory



15



CHEST PAIN(17,21,30,36,37,42,43)


• The patient expresses pain,• The patient is restless and anxious,• Pain lasts less than 20 min. in ischemic

events without necrosis,• ST depression or elevation, T wave

changes may be seen,• Detection of myocyte enzymes and

some other molecules (cTnT, cTnI,

myoglobin, CK-MB, CK etc.) in serumand increasing levels indicate myocytenecrosis. Enzyme levels are in parallelwith extent of necrosis.

• Presence of hemodynamic instabilitysigns (systolic BP <90 mmHg, meanarterial pressure <60 mmHg, heart rate>100 bpm, cardiac index <2.2l/min/m2, urine flow <30 ml/hindicates that ischemic area is largeand that the risk is high.

AIM

• Alleviation of pain,• Supporting the

circulation.

CAUSE

• Myocardial chestpain occurs whencoronary perfusionis relativelyinadequate as aresult of absoluteor increased needof supply. Chest

pain is a sign ofsevere ischemia.Pain starts beforenecrosis developsand disappears ifischemia ends orworsens if ischemiacontinues.

INTERVENTIONS

• Characteristics of myocardial ischemia are evaluated,• BP and pulse are evaluated,• Medications are given according to the physician's

orders (nitroglycerin, β-blockers, heparin, morphinesulfate, antiaggregants and GPIIb/IIIa receptorantagonists, dopamine, dobutamine etc.)

• Effectiveness of treatment is monitored,• ECG changes accompanying pain are monitored,• The patient is followed-up for arrhythmia,• 12-lead ECG is done,• Oxygen is given (SaO2 is held over 92%),• Urine volume is checked.

ASSESSMENT

Expected Outcomes• Absence of pain,• Absence of Q wave in

12-lead ECG,• Systolic BP >90 mmHg,• MAP >60 mmHg,

• Heart rate 60-100 bpm,• Cardiac index >2.2L/min/m2,

• Urine volume >30 ml/h,• No elevation of markers

such as cardiac enzymes.



16



ARRHYTHMIA(5,17,23,33,36,44,45)


• Changes in ECG,• Consciousness disorder,• Extreme increase or decrease or

irregularity of pulse rate and/ordecrease in amplitude,

• Pale, cold or damp skin.

AIM

• Preventing thedevelopment ofarrhythmia,

• Eliminatingarrhythmia,

• Keeping thearrhythmias thatcannot be

eliminated withinan acceptablerange.

CAUSE

• Inability to deliversufficient O2 to themyocardium,

• Type of contrastmedium given,

• Rapid infusion orinfusion of toomuch contrast

medium,• Electrolyteimbalance (too lowor too high levelsof potassium,calcium,magnesium,sodium).

INTERVENTIONS

• Vital signs are assessed,• Level of consciousness is assessed,• Pulse is checked (see pulse assessment, p.28),• Skin perfusion is evaluated,• 24-hour cardiac monitorization is provided after

PTCA/PVI,• Emergency medications should be ready for use,• Transient (transvenous or transthoracic) pacemaker is

held ready for use,• Medical therapy (atropine, lidocaine, amiodarone, β-

blockers etc.) is applied according to the physician'sorders.

ASSESSMENT

Expected Outcomes• Stabilization of cardiac

rhythm.



17


NURSING DIAGNOSIS- 6

DECREASED CARDIAC OUTPUT(17,23,24,31,33-35,37,44)


• Tachycardia,• Hypotension,• Restlessness,• Light headedness,• Cold and damp skin,• ↑ PCWP,• High-pitched fine crepitations in

the pulmonary region,• Urine volume of <30 ml/h,• Increasing pulse amplitude,• Capillary filling time of >3 sec.

AIM

• Early diagnosis ofsymptoms andsigns showing adecrease incardiac output,

• Prevention ofcomplications,

• Increasing cardiac

output to thenormal level.

CAUSE

• Decrease in circulatingvolume,

• Blood loss,• Cardiac tamponade,• Arrhythmia,• Myocardial ischemic

dysfunction or necrosis(myocardial infarction),

• Valvular tear or rupturecausing heart failure,• Increase in pulmonary

arterial pressure andpulmonary vascularresistance due to right-leftshunt through the septa,

INTERVENTIONS

• Hemodynamic status of the patient is closely monitored;

changes are recorded until vital signs are stabilized,• Monitorization continues until improvement in the

following parameters are provided: BP, PCWP, CVP,cardiac output and oxygen saturation,

• 12-lead ECG is done and evaluated,• If chest pain is present 2-4 ml/h O2 is given and the

physician is informed,• Cardiac enzymes and other markers are monitored

according to the physician's order,• Hourly and daily fluid intake and output are monitored,

• Urine volume of than less than <30 ml/h is reported tothe physician,

• Oral feeding of the patient is restricted (possiblesurgery),

• Necessary medications according to the physician'sorder (nitrates, calcium antagonists, beta blockers,heparin, diuretics, inotropic agents etc.),

• The patient is assessed for symptoms such asdisorientation, confusion, fatigue, increasing restlessness.

ASSESSMENT

Expected Outcomes

• Obtaining adequatecardiac output; warm anddry skin,

• Normal BP,• Pulse rate of 60-100

bpm,• Absence of crepitations,• Normal PCWP,• Urine volume of more

than 30 ml/h.



18



DECREASE IN PERIPHERAL TISSUE PERFUSION(24,28,30,33,35,37,39,45,46)


• Decrease or absence of pulseamplitude in the affectedextremity,

• Capillary filling time of >3 sec.in the affected extremity,

• Pallor, mottling and cyanosisdeveloping at the distal regionof the affected extremity,

• Decrease in voluntarymovements and senses.

AIM

• Providing adequateperipheral tissueperfusion.

CAUSE

• Mechanical obstruction inthe arterial or venouscannula,

• Arterial vasospasm,• Thrombus formation,• Embolization,• Immobility,• Bleeding or hematoma.

ASSESSMENT

Expected Outcomes• Palpable pulses,• Disappearance of

ischemic pain,• Presence of senses,

warm and pinkskin at theextremity.

INTERVENTIONS

1-Before Cannula Removal• Presence and quality of the pulse are assessed and recorded,• Unpalpable pulses are checked by Doppler ultrasound according

to the physician's order and the pulse location is marked.• Colour and temperature of all four extremities are assessed and

recorded,• All extremities are assessed for pain, numbness, loss of sensation,

motor and sensory functions and the findings are recorded,• Bed rest is provided,• The cannulated extremity is held straight with the aid of knee

and leg immobilizers,• The patient is not allowed to be in a seated position (head of

the bed should not be elevated more than 30 degrees),• Assistance is provided for feeding and excretory functions of the

bedridden patient

2- After Cannula Removal• Presence and quality of pulses at the distal of the extremity with

an arterial cannula are evaluated (radial and ulnar pulses inbrachial interventions, arteria dorsalis pedis and a. tibialisposterior pulses in femoral interventions),

• Site of intervention is assessed for swelling and hematomaformation,

• Development of pseudoaneurysm and arteriovenous fistula isassessed (a pulsatile mass, systolic inguinal pain, systolic murmur),

• The patient is prepared for surgical intervention when needed

(peripheral arterial embolectomy etc.).



19



RISK OF THROMBOEMBOLISM(6,8,31,34,39,47,48)


In thromboembolic events in theextremities;• Pain, edema in the extremity,• Unusual warmth and/or

Homans’ sign,• Decrease in pulse amplitude• Coldness and pallor at the

extremities.

In cerebral, coronary and pul-monary thromboembolic events;• Decrease in level of

consciousness, changes insensory and motor functions,

• Sudden onset chest pain,• Dyspnea and irritability,• Significant decrease in SaO2

AIM

• Prevention ofthromboembolism,

• Early diagnosis ofsigns andsymptoms ofthromboembolism,

• Prevention ofcomplications.

CAUSE

• Decrease in peripheralperfusion.

INTERVENTIONS

For interventions involving the extremities;• The extremity is checked for pallor, numbness, color change,

bleeding and hematoma,- Once every 15 minutes the first hour,- Once every 30 minutes for the next two hours,- Once every 60 minutes for the next 4 hours,- Once every 4 hours until the patient is stabilized.• Bed-rest is provided in a supine position,• Heparin is infused according to the physician's order.

In cerebral thromboembolic events;• Bed rest, neurological consultation and anticoagulant treatment

according to the physician's order, if needed.In pulmonary embolic events;• Deep breath exercises every hour in suitable patients,• Avoidance of Valsalva manoeuvre,• Anticoagulant and fibrinolytic treatment according to the

physician's order.In coronary thromboembolic events;• Antiplatelet, anticoagulant, fibrinolytic treatment according to

the physician's order.

ASSESSMENT

Expected Outcomes• Absence of pain,

edema andnumbness in theextremities,

• Return of normalskin temperatureand color,

• Normal mentalstatus,• Normal sensory

and motorfunctions,

• Disappearance ofchest pain anddyspnea,

• SaO2 in the normalrange.



20



BLEEDING(6,17,23,34,37,39,42,43,45,49,50)


• External bleeding,• Internal bleeding (into

anatomical spaces or withintissues)

• Swelling due to bleeding(hematoma formation)

AIM

• Prevention ofbleeding,

• Stopping thebleeding,

• Elimination ofcomplications ofbleeding.

CAUSE

• Hemorrhagic diathesisdue to treatment orpatient characteristics,

• Use of wide cannula,• Inadequate pressure

applied on the site ofintervention.

INTERVENTIONS

• Site of intervention is followed for bleeding (blood on bandage, pain, swelling, hematoma),• Symptoms and signs of retroperitoneal bleeding are monitored (side pain, decrease in

amplitude of extremity pulses, decrease in Htc and Hb levels),• After the procedure vital signs are monitored until they are stabilized (BP and pulse may

be indicators of bleeding),• Prothrombin time, partial thromboplastin time, activated coagulation time (ACT) and

platelet levels are monitored.If there is significant bleeding;- Vital signs are monitored every 15 minutes until bleeding is controlled,- Circulation of the extremities is checked,- Amount of blood on the bandage is evaluated and recorded,- If hematoma is present, it is marked on the skin starting from the outer borders.Before Cannula Removal;- The limb is held straight in a resting position,- The head of the bed is elevated with an angle of less than 30 degrees,- A suitable position for feeding, excretory functions and necessary position changes are provided,- Frequent movements of the limb on which the intervention is done are avoided,• The patient is taught to apply pressure on the site of intervention during coughing,

sneezing and head elevation with a pillow,• The patient is told to inform the nurse when he/she feels temperature rise, dampness or

swelling at the site of intervention,

• Antiplatelet drugs are ceased according to the physician's orderIf there is serious bleeding;- The physician is informed,- Infusion of anticoagulants (heparin, low molecular weight heparin), antiaggregants

(GPIIB/IIIA receptor blockers) and fibrinolytic agents is ceased after consulting the physian,- Bandage at the bleeding site is changed; manual or mechanical pressure is applied,- The cannula is removed by the physician if necessary,- Fluid infusion is started according to the physician's order.Following Cannula Removal;- Pressure is applied for 30 minutes according to the clinical protocol,- Bed rest in supine position is provided according to the clinical protocol,

- Sudden movements are avoided until wound closure and clot formation is complete,- Mobilization of the patient is started according to the clinical protocol.



22



ALLERGIC REACTION(15,20,25,42,45)


• Pruritus, urticaria,• Rash,• Feeling of warmth,• Dyspnea,• Fever,• Anaphylaxis.

AIM

• Prevention anddiagnosis ofallergic reactionand symptomatictreatment.

CAUSE

• Contrast medium use.

INTERVENTIONS• Allergy against contrast medium is investigated,• The patient is told to give information in case of- Pruritus, feeling of warmth- Nausea and vomiting, malaise- Dyspnea• Vital signs are closely monitored,• Antihistamines/corticosteroids/pressor amines are given

according to the physician's orders when needed,• Life supporting measures are taken if the reaction is severe,

• Psychological support is provided for the patient.

ASSESSMENTExpected Outcomes• No signs of allergic

reactions areobserved in thepatient.



24


5.2. Patient/Family Education BeforeDischarge(20,21,25,31,35,36,38,39,42-46)

After discharge the patient is planned to be able to take care of the site of

intervention, to recognize symptoms and signs of complications and to developbehaviour aiming to reduce risk factors.

A. Giving General Information

• Information on the procedure to be performed and on the results is given,• Level of information given during the training before PTCA/PVI is checked and

missing issues or misunderstood subjects are identified and the education isrepeated when necessary,

• One of the family members should be ready for assisting the patient duringhospital discharge.

B. Symptoms and Signs that Should be Reported

Symptoms and signs of emergency situations, information on possiblecomplications are overviewed and the patient is told to admit to a health carefacility if one of these conditions is present.

The patient is told to inform the nurse in the presence of the following conditions;

• Continuing chest pain (pain not alleviating despite use of nitroglycerine 3 times

with intervals of 15 minutes and lasting more than 15 minutes),• Irregularity of pulse, light headedness,• Weight gain of 1-2 kg/day or 3-5 kg/week,• Lack of energy and fatigue,• Shortness of breath with minimal physical effort,• Changes at the site of intervention (except slight ecchymosis and firmness)

- Recent bleeding at the site of cannula insertion,- A recently forming and growing swelling,- Redness, swelling, discharge or feeling of warmth at the extremity on which

the procedure is performed,

- Insensitivity, numbnessC. Special Considerations

The patient is told that;• He/she would better have assistance when going home after hospital discharge,• He/she can remove the gauze pad at the site of insertion one day later,• He/she can take a bath without rubbing the site of intervention (if the permission

to take a bath is given)• Tight clothes should be not worn until the sensitivity at the site of intervention

diminishes,• Protective bandage can be used if the underwear touches the site of intervention.



25


D. Mobility

• Avoidance of intense activity for the first week (swimming, running, biking,dancing, climbing up the stairs etc.),

• Protection of the site of cannula insertion from trauma.The patient is told;

• Not to carry, push or pull heavy objects for the first 2-3 days,• Not to drive for at least one week,• To avoid ascending the stairs for the first 2 days (if obligatory, the leg

contralateral to the limb on which the procedure is performed is advanced firstplacing it on the step above and than the other leg is advanced up to the samestep,

• To avoid sexual activity for 2-3 days following the intervention,• To avoid constipation and straining and to inform the physician/nurse about these

symptoms,• When to start working (usually one week later).

E. Medical treatment

The following explanations are made:• Name of the medication and why it is used,• How many mgs of drug each tablet or capsule contains,• How many times a day and how the medications will be used,

• How and where the medications should be kept,• Most common side effects and the importance of reporting them to the

physician/nurse when they occur,• Importance of regular use and avoidance of missing doses,• Importance of not ceasing the medication without consulting the physician.

F. Modification of risk factors

Saves more lives than all therapeutic interventions. See Guidelines for Preventionand Treatment of Coronary Heart Diseases 2002 and Nursing Care Guidelines for

Heart Failure - Acute Coronary Syndromes - Hypertension 2003 for more details.Diet: Low-cholesterol diet according to the physician's recommendations; weight

loss is recommended if necessary,

Physical activity: Importance of compliance with the physician'srecommendations on physical activity is explained,

Smoking: Importance of quitting smoking is emphasized,

Alcohol consumption: Avoidance of excessive consumption is recommended.

Patient-specific limits are determined by the physician,



26


G. Importance of regular visits for maintenance of well-being isexplained to the patient and the family.

• For continuity of the education, written materials (booklet, brochure etc.) on

patient care are provided for the patient and the family,• Names and phone numbers of the physician and the nurse to be called up whenneeded are given to the patient.

6. PULSE ASSESSMENT(49,51)

• Presence,• Amplitude (fullness),• Rate,• Rhythm of the pulse are assessed.

Presence of pulse is assessed in all arteries from head to toe bilaterally

• Carotid arteries (assessed without pressing)• Radial arteries• Femoral arteries• Popliteal arteries• Aa. dorsalis pedis• Aa. tibialis posterior are especially important. Doppler USG can be used if these

arteries cannot be palpated.

Pulse Amplitude

Pulse amplitude may give a rough and quick idea on blood pressure and cardiacoutput.

Pulse amplitude is scored from 0 to 4.0 = The pulse is not palpable+1 = The pulse is weak or thready

+2 = The pulse is normal+3 = The pulse is bounding+4 = The pulse is hyperkinetic and visible to the eye without palpation,Pulse rate and rhythm are compared bilaterally at the same time.



27


Table 1: Agents Commonly Used in PTCA and PVI(20,24,30,31,40,44,52-57)

Calciumantagonists

Beta blockers

Nitroglycerin

Positiveinotropicagents

Diuretics

Atropine

Lidocainehydrochloride

Antiaggregantagents-Aspirin

-Ticlopidine

-Clopidogrel

Anticoagulanttherapy

-Standardheparin

-Low molecular weight heparin(LMWH)

GlycoproteinIIb/IIIaReceptorAntagonists

-Abciximab -Tirofiban

-Eptifibatide

• They inhibit calcium entry to myocytes and smooth muscle cells. Some ofthem may decrease myocardial contractility and rate of conduct. Theydilate coronary arteries and arterioles.

• They decrease heart rate, cardiac contractility and oxygen requirement.• They are generally useful for coronary syndromes with chest pain except

myocardial infarction. They decrease ventricular filling pressure andsystemic vascular resistance and increase collateral flow.

• They are used for conditions where myocardial contractility is decreased.Digoxin, dopamine and dobutamine are the most frequently used agents.Dopamine and dobutamine are more often used for severe hemodynamicfailure such as cardiogenic shock.

• They are used to alleviate congestive symptoms. Furosemide, a loopdiuretic, is the treatment of choice. Loop diuretics inhibit sodium andchloride reabsorbtion at the ascending proximal part of Henle's loop.

• It is an anticholinergic agent that inhibits acetylcholine at theparasympathetic neuromuscular junction. It increases heart rate bydecreasing parasympathetic inhibition on sinus node and atrioventricularnode.

• It belongs to Class Ib antiarrhythmic agents used for ventricularextrasystols that cause symptomatic and hemodynamic impairment. It actsby shortening action potential duration.

• Inhibits cyclooxygenase, an enzyme involved in the synthesis ofthromboxane A2 which causes aggregation of platelets. Consequently,tendency of platelets to adhere to each other and to vessel walls and toaggregate is decreased. Daily dose is 75-325 mg. Acute treatment dose

is 150-300 mg/day and chronic treatment dose is 80-100 mg/day.• Inhibits platelet aggregation and release of platelet derived factors.

Inhibits binding of fibrinogen to platelet memebrane via ADP. Ticlopidineprevents ADP-induced platelet aggregation. Antiaggregant activity isincreased when used concurrently with aspirin. This combined usemarkedly increased the safety of PTCA and coronary stent placement andextensively decreased early occlusions.

• Acts like ticlopidine, has less side effects and is generally used for thesame indications.

• Prevents thrombus formation at the the site of PTCA by speeding up thesynthesis of antithrombin III–thrombin complex. Inactivates thrombin and

prevents the conversion of fibrinogen to fibrin. Duration of its effect is 4hours and the activity is monitored by aPTT.• They are derived from standard heparin. They have a lower molecular

weight and are given every 12 hours. There is no need for aPTT control.Some of these agents –enoxaparine– are shown to be superior tostandard heparin in acute coronary syndromes.

• They are used for high-risk coronary artery interventions in non-ST segmentelevation myocardial infarction. They prevent binding of platelets to eachother via fibrinogen bridges by blocking GPIIb/IIIa receptors. Reductionof heparin doses should be considered when they are used with heparinor LMWH.



28


7. REFERENCES

1) Freed M, Gines C. Manual of Interventional Cardiology. 2nd Edition. Michigan:Physician’s Press Birmingham; 1992.

2) Hillis LD, Lange RA, Winniford MD, Page RL. Kardiyolojide Klinik Problemler El Kitab›(Manual of Clinical Problems in Cardiology); Editör: Hisar ‹. Ankara: Bilimsel T›pYay›nevi; 1996. p.167-76.

3) Oral D, Ömürlü K. Koroner anjiyoplastide yeni teknolojik uygulamalar (Newtechnological applications in coronary angioplasty). Kardiyoloji 1994;1:64-85.

4) Türk Giriflimsel Kardiyoloji Dergisi (Turkish Journal of Interventional Cardiology)2000;4(3):129-81.

5) Oto A, Oktay E. Türkiye’de giriflimsel kardiyoloji alan›nda yaflanan sorunlar vemuhtemel çözüm önerileri (Problems and recommendations for potential solutions oninterventional cardiology in Turkey). T›p Dünyas› 2003;(98):1-4.http://www.ttb.org.tr

6) Braunwald ZL. Heart Disease. A Text Book of Cardiovascular Medicine. 6th Edition.Philadelphia: WB Saunders Company; 2001. p.1364-92.

7) Reynolds S, Waterhouse K, Muller HC. Head of Bed Elevation, Early Walking, andPatient Comfort After Percutaneous Transluminal Coronary Angioplasty. Dimensions ofCritical Care Nursing 2001:44.

8) Topol EJ. Textbook of Interventional Cardiology. 4th Edition. Philadelphia: WBSaunders Company; 2003. p.141-63.

9) Donald SB. Coronary angioplasty. In: Cardiac Catheterization, Angiography and

Intervention. 5th Edition. Philadelphia: Williams&Wilkins; 1996. p.537-62.10) Apple S, Lindsay J. Giriflimsel Kardiyoloji (Interventional Cardiology). ‹stanbul: Nobel T›p

Kitabevleri; 2003. s.9-213.11) Stephen GE. Elective coronary angioplasty: technique and complications. In: Cardiac

Catheterization, Angiography and Interventions. 5th Edition. Philadelphia: Williams &Wilkins; 1996. p.186-201.

12) Ulrich S. An overview of intravascular stents: old and new. In: Cardiac Catheterization,Angiography and Interventions. 5th Edition. Philadelphia: Williams & Wilkins; 1996.p.812.

13) Pepine CJ, Hill JA, Lambert CR. Diagnostic and Therapeutic Cardiac Catheterization.Baltimomer: Williams & Wilkins; 1994. p.471-598.

14) Urden LD, Stacy KM. Priorities in Critical Care Nursing. 3rd Edition. Philadelphia:Lippincott Company; 2000. p.194-7.

15) Binak K, ‹lerigelen B, Güzelsoy D, Okay T. Teknik Kardiyoloji (Technical Cardiology).2nd Edition. ‹stanbul; 2001. p.355-67.

16) Davies C, Van Riper S, Long Street J. Vascular complications of coronary interventions,heart & lung. The Journal of Acute & Critical Care 1997;26(2):118-27.

17) Woods S, Frolicher ES, Motzer SU. Cardiac Nursing. 4th Edition. Philadelphia:Lippincott Williams & Wilkins; 2000. p.544-57.

18) Hartshorn JC, Sole ML, Lamborn ML. Introduction to Critical Care Nursing. 2nd Edition.Philadelphia: WB Saunders Company; 1997. p.254-6.



29


19) Özmen F, Oral D, Türko¤lu C, et al. Türkiye’de invazif kardiyoloji: 1995 y›l› sonuçlar›(Invasive cardiology in Turkey: Outcomes in 1995). Türk Giriflimsel Kardiyoloji Dergisi1997;(2):79-84.

20) Kern MJ. The Cardiac Catheterization Handbook. 3rd Edition. St Louis; 1999. p.4-159.

21) Dincher JR, Harkness GA. Medical Surgical Nursing, Total Patient Care. 9th Edition. StLouis: Mosby; 1996. p.663.

22) Feyter PJ. ‹skemik kalp hastal›¤›n› tedavi etmek için kateter teknikleri (Techniques ofcatheterization for the treatment of ischemic heart disease). ‹stanbul; 2003;20:13.

23) Swearingen PL, Keen JH. Nursing Interventions and Collaborative ManagementManual of Critical Care Nursing. 3rd Edition. St Louis: Mosby; 1995. p.328-33.

24) Hudak CM, Gallo BM, Beriz JJ. Critical Care Nursing. 5th Edition. Philadelphia: JBLippincott Company; 1990. p.174-2001.

25) Grossman W, Baim DS. Cardiac Catheterization, Angiography and Intervention. 4th

Edition. Philadelphia: Lea & Febiger; 1991. p.441-65.26) Safian RD, Freed MS. The Maual of Interventional Cardiology. 3rd Editon. Michigan:Physicians Press; 2001. p.74-75.

27) Reeves CJ, Roux G, Locckhart R. Medical-Surgical Nursing. New York; 1999. p.97-9.28) Fohey AV. Vascular Nursing. 4th Edition. Missouri: Saunders; 2004. p.101-8.29) Linton AD, et al. Introductory Nursing Care of Adults. 2nd Edition. WB Saunders

Company; 2000. p.591.30) Ignatavicius DD, Workman ML, Mishler MA. Medical-Surgical Nursing, Volume I. 2nd

Edition. Philadelphia: WB Saunders Company; 1995. p.942-1005.31) Thompson JM, McFarland GK, Hirsch JE, Tucker SM. Mosby’s Clinical Nursing. 5th

Edition. St Louis: Mosby; 2002. p.134-7.32) Birol L. Hemflirelik Süreci (The Nursing Process). 3rd Edition. ‹zmir: Etkin Matbaac›l›k;

1997. p.120-1.33) Thompson JM, Tucher SM, Bowers AC, McFarland GK, Hirsch JE. Mosby’s Manual of

Clinical Nursing. 2nd Edition. St Louis: Mosby; 1989. p.111-3.34) 9th American Nurses Association and American Heart Association Standards of

Cardiovascular Nursing Practice. 6th Edition. Washington: American NursesPublishing; 1994.

35) 10th American Nurses Association Standards of Clinical Nursing Practice. 4th Edition.Washington: American Nurses Publishing; 1997.

35) Urden LD, StacyKM, Mary L. Thelan’s Critical Care Nursing: Diagnosis andManagement. 4th Edition. St Louis: Mosby; 2002. p.457-65.

36) Carpenito JL. Nursing Care & Documentation. 3rd Edition. Philadelphia: LippincottWilliams & Wilkins; 1999. p.143-55.

37) Gulanic M, Myers JL. Nursing Care Plans: Nursing Diagnosis and Intervention. 5thEdition. St Louis: Mosby; 2004. p.298-305.

38) Holloway NM. Medical-Surgical Care Planning. 4th Edition. Philadelphia: LippincottWilliams & Wilkins; 2004. p.432-9.

39) Jones C, Holcomb E, Rohrer T. Femoral artery pseudoaneurysm after invasive

procedures. Critical Care Nurse 1995;15:47-51.40) Black JM, Matassarin-Jacobs E. Medical-Surgical Nursing. 4th Edition. Philadelphia:




WB Saunders Company; 1993. p.1144-287.41) Phipps WJ, Sands JK, Marek JF. Medical-Surgical Nursing: Concepts & Clinical

Practice. 6th Edition. St Louis: Mosby; 1999. p.645-63.42) Apple S, Lindsay J. Interdiciplinary Management of the Interventional Patient Principles

and Practice of Interventional Cardiology. Philadelphia: Lippincott Williams & Wilkins;2000. p.229-50.

43) Canobbia MM. Mosby Handbook of Patient Teaching. Missouri: Mosby Year BookInc.; 1996. p.517-9.

44) Dressler DK, Gettrust KV. Cardiovascular Critical Care Nursing. New York: DelmarPublisher; 1994. p.50-65.

45) Thelan LA, Urden LD, Lough ME, Stacy KM. Critical Care Nursing DiagnosisManagement. Philadelphia: A Times Mirror Company; 1998. p.590.

46) Tucker SM, Canobbia MM. Patient Care Standards Collaborative Planning & Nursing

Interventions. St Louis: Mosby Company; 2000. p.154-6.47) Enç N. Pulmoner embolizm (Pulmonary Embolism). Yo¤un Bak›m Hemflireleri Dergisi1997;1:41-7.

48) O’Brien C, Recke D. How to remove a femoral sheath. American Journal of Nursing1992:34.

49) Woods SL, Froelicher ES, Motzer SA, Bridges EJ. Cardiac Nursing. 5th Edition.Philadelphia: Lippincott Williams & Wilkins; 2005. p.239-41.

50) Homes LM, Hollabaugh SK. Critical Care Nursing the Continuous Quality ImprovementProcess to ‹mprove the Care of Patients After Angioplasty Vol:17, No:6, 1997. p. 56-65

51) Fuller J, Schaller-Ayers J. Health Assessment A Nursing Approach. 2nd Edition.Philadelphia: JB Lippincot Company; 1994. p.250-5.

52) Karch AM. 2003 Lippincott Nursing Drug Guide. Philadelphia; 2003. p.74-1157.53) Komfluo¤lu B. Klinik Kardiyoloji, Kardiyovasküler ‹laç Rehberi. ‹stanbul: Nobel T›p

Kitabevleri Ltd.; 2000. p.405-17.54) Kozan Ö. Manual of Acute Coronary Syndromes. ‹zmir; 2002. p.176-8.55) Okay T. Acute Coronary Syndromes 1; Evidence-based cardiology (K›lavuzlar

çerçevesinde kan›ta dayal› kardiyoloji). ‹stanbul; 2002. p.58-60.56) Crawford MH, DiMarco JB. Cardiology. Toronto: Mosby; 2001. p.2-5.57) Günefl B. Cardiovascular Pharma List, Türkiye Kalp-Damar ‹laçlar› Rehberi. Ankara:

Farma T›p Yay›nc›l›k; 2003.

TKD NursingGuidelines Percutaneous

Documents

Transcript of TKD NursingGuidelines Percutaneous